Paclitaxel-eluting versus bare-metal stents in acute ST elevation myocardial infarction (STEMI).

INTRODUCTION: Data comparing efficacy and safety of drug eluting stents (DES), particularly paclitaxel stent with bare metal stents (BMS) in the setting of acute ST elevation myocardial infarction (STEMI) is limited and inconclusive. The aim of our study is to compare the efficacy and safety of paclitaxel stent with bare metal stent in acute STEMI. METHODS: A retrospective cohort study was performed on patients from our single community hospital who participated in the C-PORT trial from January 2003 to May 2005. One hundred forty-three patients treated exclusively with either BMS or paclitaxel DES were included (79 with paclitaxel DES and 64 with BMS) and were followed at 1, 3, and 6 months. The primary outcome was occurrence of major adverse cardiac events defined as cardiac death, STEMI or NSTEMI or the need for target vessel revascularization. Variables were compared using appropriate statistics and event free survival curves were estimated. RESULTS: Baseline clinical characteristics in BMS and paclitaxel DES groups were well matched. No statistical difference between BMS and DES groups in the rate of cardiac death (6% vs. 9%, P = 0.56), STEMI or NSEMI (1.6% vs. 1.3% respectively, P = 0.88) and composite end point (13% vs. 10%, P = 0.65) was observed while a significant reduction in target vessel revascularization was seen in DES group (6% vs. 0% respectively, P = 0.02) was noticed. CONCLUSION: In our patient group with acute STEMI, the use of paclitaxel DES did not show significant decrease in cumulative end points, cardiac mortality and recurrent STEMI or NSTEMI compared with BMS over a 6-month follow-up period. However, a significant reduction in revascularization of target vessel was seen.

Maryland's first inpatient chest pain short stay unit as an alternative to emergency room-based observation unit.

INTRODUCTION: Approximately 8 million people in the United States visit emergency rooms (ERs) annually for chest pain but only about 1.2 million were ultimately diagnosed with acute myocardial infarction. Of concern, up to 4% to 5% of patients with acute myocardial infarction are those inappropriately discharged from the ER. ER-based observation units (EROU) were developed to enable safe, expedited, and effective management of these patients with negative initial workup. In the state of Maryland, the unique reimbursement system serves as a disincentive to operate EROU. The inpatient chest pain short stay unit (CPSSU) at St. Agnes hospital is the first in Maryland dedicated to evaluating patients with chest pain. We study the performance of CPSSU as compared with that of EROU. METHODS: The project is a prospective observational study that involved consecutive patients presenting to St. Agnes ER with the primary complaint of chest pain between June 1, 2005 and November 30, 2005. After negative initial electrocardiograms and cardiac enzymes, the patients were further evaluated using a standard CPSSU protocol in ER or CPSSU. Primary outcome variables were myocardial infarction or death. RESULTS: A total of 332 patients were enrolled among which 202 were worked up in ER and 130 in CPSSU. There were no deaths and only 1 patient with significant coronary artery disease, representing 0.3% of study population was missed. Thirteen patients (3.9%) were detected with significant coronary artery disease. Severe 3 vessel disease was found in 4 (1.2%) patients. Median cost (and revenue) of evaluation in ER and CPSSU was $978.323 ($1203.533) and $1543.287 ($2947.85), respectively. CONCLUSION: Inpatient CPSSU initiative is an effective alternative to EROU for evaluating chest pain patients with negative initial workup. Furthermore, this is achieved with net profit gain of $1744.37 over that of EROU evaluation.

Saw palmetto-induced pancreatitis.

Saw palmetto is a frequently used botanical agent in benign prostatic enlargement (BPH). Although it has been reported to cause cholestatic hepatitis and many medical conditions, Saw palmetto has not been implicated in acute pancreatitis. We report a case of a probable Saw palmetto induced acute hepatitis and pancreatitis. A 55-year-old reformed alcoholic, sober for greater than 15 years, presented with severe non-radiating epigastric pain associated with nausea and vomiting. His only significant comorbidity is BPH for which he intermittently took Saw palmetto for about four years. Physical examination revealed normal vital signs, tender epigastrium without guarding or rebound tenderness. Cullen and Gray Turner signs were negative. Complete blood count and basic metabolic profile were normal. Additional laboratory values include a serum amylase: 2,152 mmol/L, lipase: 39,346 mmol/L, serum triglyceride: 38 mmol/L, AST: 1265, ALT: 1232 and alkaline phosphatase was 185. Abdominal ultrasound and magnetic resonance cholangiography revealed sludge without stones. A hepatic indole diacetic acid scan was negative. Patient responded clinically and biochemically to withdrawal of Saw palmetto. Two similar episodes of improvements followed by recurrence were noted with discontinuations and reinstitution of Saw Palmetto. Simultaneous and sustained response of hepatitis and pancreatitis to Saw palmetto abstinence with reoccurrence on reinstitution strongly favors drug effect. "Natural" medicinal preparations are therefore not necessarily safe and the importance of detailed medication history (including "supplements") cannot be over emphasized.